Objective

Previous work has shown an intricate connection between music processing and movement in the brain. This overlap is also present for imagined music, and may as such be applied to existing imagery-based movement rehabilitation paradigms. In the following proposal we outline two main questions. The first concerns the extent of the involvement of motor areas during music processing in various modes, namely perception, auditory imagination, auditory-motor imagination and observation. Common and separate brain activation patterns will be assessed using fMRI. The second question addresses the effects of imagery training paradigms on plastic changes in the brain, and the effect of cuing during this training. Pre- and post training fMRI will be measured as well as the behavioral output of the training. These questions will address unanswered issues that are relevant to existing movement rehabilitation paradigms. Additional to furthering our knowledge of imagery mechanisms in the brain, the results will be directly applicable to the clinical arena, as well as training in high-level skill acquisition.

Virtual Reality applications for integrated cognitive and motor stroke rehabilitation show promise for providing more comprehensive rehabilitation programs. However, we are still missing evidence on its impact in comparison with standard rehabilitation, particularly in patients with cognitive impairment. Additionally, little is known on how specific stimuli in the virtual environment affect task performance and its consequence on recovery. Here we investigate the impact in stroke recovery of a virtual cognitive-motor task customized with positive stimuli, in comparison to standard rehabilitation. The positive stimuli were images based on individual preferences, and self-selected music (half of the sessions). 13 participants in the subacute stage of stroke, with cognitive and motor deficits, were allocated to one of two groups (VR, Control). Motor and cognitive outcomes were assessed at end of treatment (4-6 weeks) and at a 4-week followup. Both groups showed significant improvements over time in functional ability during task performance, but without changes in motor impairment. Cognitive outcomes were modest in both groups. For participants in the VR group, the score in the task was significantly higher in sessions with music. There were no statistical differences between groups at end of treatment and follow-up. The impact of VR therapy was lower than in similar studies with stroke patients without cognitive deficits. This study is a first step towards understanding how VR could be shaped to address the particular needs of this population.

Dr Norman Doidge has travelled the world meeting people who have healed themselves using neuroplasticity—the brain’s ability to change in response to stimuli and experience. He told Lynne Malcolm how the concept may change the way we treat everything from ADD to Parkinson’s.

Scientists now know that the brain has an amazing ability to change and heal itself in response to mental experience. This phenomenon, known as neuroplasticity, is considered to be one of the most important developments in modern science for our understanding of the brain.

The brain is not fixed and unchangeable, as was once thought, but can create new neural pathways to adapt to its needs. This has led to an explosion of interest in the power of brain training to improve our focus, memory attention and performance.

Dr Norman Doidge, A psychiatrist and researcher from the University of Toronto in Canada, put neuroplasticity in the spotlight in 2007 when he released his bestseller The Brain That Changes Itself.

The thing that is so beautiful about this is it’s something that anyone has access to.

DR NORMAN DOIGE

Since then he’s explored the powerful therapeutic potential of neuroplasticity and demonstrated that the brain has its own unique way of healing .

His latest book, The Brain’s Way of Healing: Remarkable Discoveries and Recoveries From the Frontiers of Neuroplasticity, tells the stories of patients benefiting from neuroplasticity, healing their brains without medication or surgery.

In conditions such as multiple sclerosis, Parkinson’s disease, autism and attention deficit disorder, the brain’s general neuronal and cellular health goes awry.

The problems may be the result of inflammation, toxicity or genetically induced celluar abnormalities. Circuits may die, become dormant or begin firing at irregular rates. Doidge calls this a ‘noisy brain’.

‘Think of people with traumatic brain injury,’ he says. ‘There are certain things they can’t do anymore, and that’s because circuits are dormant, but there are other circuits that seem to be hyperactive.

‘They are very, very sensitive to sounds and light and so on: that all has to be rebalanced. Then the brain goes through a period of rest and then it goes through learning.’

In The Brain’s Way of Healing, Doidge describes interventions that are non-invasive and use the senses or movement of the body to access the brain.

Doidge tells the story of John Pepper, who has Parkinson’s. The disease is a result of damage to the dopamine-producing cells in the brain that help us make automatic movements. This damage leads to difficulties with movement, balance and walking.

Pepper wasn’t responding to conventional medication, but began to pay very close attention to the individual movements involved in walking when he joined his wife in a get-fit program.

‘What he found was that he could do movements with that level of awareness, by breaking it down, because that’s not broken in the Parkinson’s brain,’ says Doidge. ‘He was actually using another part of his brain, in the frontal lobes, to work around the Parkinson’s.’

Pepper was conscientious with his walking exercises and saw remarkable improvement in his Parkinson’s symptoms.

He was using activity, thought and movement to stimulate dormant circuitry in his brain, which found other ways to overcome the problem.

‘The thing that is so beautiful about this is it’s something that anyone has access to,’ says Doidge.

It also highlights how valuable movement—even the very simple act of walking—can be for the body and the brain. Doidge cites a recent large study by the Cochrane Institute in Wales which showed that five activities—exercise, not smoking, not drinking more than a glass of wine a day, eating four servings of fruit and vegetables daily and being a normal weight—reduce the risk of developing dementia by a staggering 60 per cent.

‘Now, if any drug did that it would be the most talked about drug in the world probably, and the most powerful factor was exercise,’ says Doidge.

The author also learned several things about pain and neuroplasticity while writing the book.

There are two kinds of pain: acute pain—a warning not to move a body part because you could cause further damage to it—and chronic pain.

Acute pain is necessary, but because the brain and nervous system are neuroplastic, the pain system itself can be injured by stimulation. Even a small movement of an injured body part can lead to pain that spreads through the body and lasts a long time.

Doidge tells the story of pain physician and psychiatrist Michael Moskowitz, who experienced disabling and chronic pain after a series of accidents.

Moskowitz read up on the scientific literature on plasticity. He found that there are about a dozen regions in the brain that process pain, and that almost all of them do other things.

You may have noticed that when you are in pain you get cranky; that’s because one of the areas of the brain that processes pain also processes emotional regulation.

Another such region processes both pain and the ability to visualise; brain scans show that chronic pain hijacks about 15 per cent of visual processing.

Moskowitz’s solution was to force himself to visualise whenever he was in pain. The idea was to reconquer that area of the brain for imagery—what Doidge describes as the ‘use it or lose it’ nature of plasticity..

‘After several weeks he started to get some results, and by several months he could go 15, 20 minutes without pain,’ says Doidge. ‘At the end of the year he had no pain. He beat back his chronic pain with this neuroplastic mental intervention.’

Many of the stories of healing Doidge tells sound almost miraculous, but he is quick to point out that they are examples from the frontiers of neuroplastic research. This is not a belief-based phenomenon, he says, nor is it due to the placebo effect. It’s about training up new brain circuitry.

‘You don’t have to believe this, you just have to be willing to do it,’ he says.

‘I really wish people would look into these things before they declared that just because they don’t fit with the existing paradigm, that they are not possible.

‘I think the scientific attitude is a systematic mature scepticism, which is sceptical of itself as well. If it encounters something that it hasn’t met before, the idea is not to roll your eyes away from it and not look at it, but to actually look at it more intensively.’

According to a prevailing view, the visual system works by dissecting stimuli into primitives, whereas the auditory system processes simple and complex stimuli with their corresponding features in parallel. This makes musical stimulation particularly suitable for patients with disorders of consciousness (DoC), because the processing pathways related to complex stimulus features can be preserved even when those related to simple features are no longer available. An additional factor speaking in favor of musical stimulation in DoC is the low efficiency of visual stimulation due to prevalent maladies of vision or gaze fixation in DoC patients. Hearing disorders, in contrast, are much less frequent in DoC, which allows us to use auditory stimulation at various levels of complexity.

The current paper overviews empirical data concerning the four main domains of brain functioning in DoC patients that musical stimulation can address: perception (e.g., pitch, timbre, and harmony), cognition (e.g., musical syntax and meaning), emotions, and motor functions. Music can approach basic levels of patients’ self-consciousness, which may even exist when all higher-level cognitions are lost, whereas music induced emotions and rhythmic stimulation can affect the dopaminergic reward-system and activity in the motor system respectively, thus serving as a starting point for rehabilitation.

Editor’s note: The use of music in therapy for the brain has evolved rapidly as brain-imaging techniques have revealed the brain’s plasticity—its ability to change—and have identified networks that music activates. Armed with this growing knowledge, doctors and researchers are employing music to retrain the injured brain. Studies by the authors and other researchers have revealed that because music and motor control share circuits, music can improve movement in patients who have suffered a stroke or who have Parkinson’s disease. Research has shown that neurologic music therapy can also help patients with language or cognitive difficulties, and the authors suggest that these techniques should become part of rehabilitative care. Future findings may well indicate that music should be included on the list of therapies for a host of other disorders as well.

The role of music in therapy has gone through some dramatic shifts in the past 15 years, driven by new insights from research into music and brain function. These shifts have not been reflected in public awareness, though, or even among some professionals.

Biomedical researchers have found that music is a highly structured auditory language involving complex perception, cognition, and motor control in the brain, and thus it can effectively be used to retrain and reeducate the injured brain. While the first data showing these results were met with great skepticism and even resistance, over time the consistent accumulation of scientific and clinical research evidence has diminished the doubts. Therapists and physicians use music now in rehabilitation in ways that are not only backed up by clinical research findings but also supported by an understanding of some of the mechanisms of music and brain function.

Rapid developments in music research have been introduced quickly into neurologic therapy (see sidebar) over the past 10 years. Maybe due to the fast introduction, the traditional public perception of music as a ‘soft’ addition, a beautiful luxury that cannot really help heal the brain, has not caught up with these scientific developments.

But music can. Evidence-based models of music in therapy have moved from soft science—or no science—to hard science. Neurologic music therapy does meet the standards of evidence-based medicine, and it should be included in standard rehabilitation care.

Stroke is the second most common cause of death and major cause of disability worldwide. Hand motor dysfunction is a common impairment in stroke patients, as the cortical projection area of our fingers is large. Once it is damaged, it will be very difficult to restore the function, and has long been the focus and difficulty of stroke rehabilitation. Music- supported therapy in recent study was shown to induce improvements in motor skills in stroke survivors.

Objective: This study aimed at assessing the motor recovery of the affected hand induced by music-supported therapy in chronic stroke patients.

Methods: 14 patients with subcortical stroke, mild to moderately impaired hand function fulfilling the inclusion criteria were randomly assigned to the music group and control group. Both groups received keyboard (Yamaha) training for 30min, 20 times over 4 weeks in addition to conventional treatments. And the only difference between the two groups was that control group’s keyboard could not make any sound. They were trained in an intensive step by step training program. Patients were assessed by Wolf Motor Function Test before and after training.

Results: Both groups showed improvement in motor function assessed by Wolf Motor Function Test scores, and the improvement in music group was significantly better than that of the control group.

Conclusions: The music-supported training with sound can enhance the restoration of hand function much better than the training with no sound in which the music played an important role.

Introduction

Stroke is the second most common cause of death and major cause of disability worldwide [1]. The majority of patients suffering from a stroke have motor impairments, preventing them to live independently. Music therapy has been used to improve patients’ health in several domains, such as cognitive functioning, emotional development, social skills, and quality of life, by using music experiences such as free improvisation, singing, and listening to, discussing, and moving to music to achieve treatment goals. Music- supported therapy (MST) in recent studies has been used in the rehabilitation of stroke survivors with mild or moderate motor disfunction [2-7]. Most of the randomized controlled trial studies were interested in the gross motor function of affected upper extremities after stroke, and the results often showed greater improvements compared with other traditional rehabilitation therapies. But the affected hand function was not especially focused on. Hand motor dysfunction is a common impairment in stroke patients, as the cortical projection area of our fingers is large. Once it is damaged, it will be very difficult to restore the function, and has long been the focus and difficulty of stroke rehabilitation. So we wanted to find out what can music-supported therapy do to the affected hand function after stroke. Since the improvement of the upper extremities after music- supported training was demonstrate, we supposed that the affected hand function would also regain after certain MST programme. It is well known that repetitive practice is one of the basic elements of music supported therapy which can induce the recovery of motor function after stroke, and we would like to find out what the music itself played part in this new therapy.

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Approximately one-third of patients with epilepsy have a drug-resistant form of the disease. But even in cases where the pharmacological treatment is effective, it is common for side-effects of anti-epileptic drugs to arise, including skin rashes, dizziness, liver damage, psychiatric symptoms, cognitive impairment, and pregnancy-associated complications.

Surgery has a good rate of success in achieving long-term remission of epilepsy symptoms, but the number of patients undergoing surgery still represents a small percentage of patients with drug-resistant epilepsy.

Therefore, alternative, non-pharmacological treatment options are sought after. Music therapy is one of them.

The “Mozart effect”

The therapeutic potential of music has been widely investigated in cognitive neuroscience. But in the specific case of epilepsy, this use of music as therapy is particularly fascinating due its dual effect.

As seen in Part 1 of the music and epilepsy diptych, on the one hand, music can induce seizures, in what is known as musicogenic epilepsy, but on the other hand, it may have a beneficial outcome, at least in some patients and with some specific melodies.

This ability of music in reducing neuronal discharges and in reducing seizures has been known for decades. The first studies used mainly pure tones or loud music stimulation to shorten the duration of seizures. But in 1998, Hughes and colleagues reported for the first time a therapeutic effect of Mozart’s music on patients with epilepsy; they demonstrated that Mozart’s Sonata for Two Pianos in D Major (K.448) exerted an acute effect on the amount of epileptic activity, both during and between seizures. They called it the “Mozart effect”.

Subsequently, various trials or case reports started using Mozart’s K.448 to reduce seizures, initially only in chronic epilepsy conditions, but recently also for acute epilepsy.

Beneficial effects of Mozart’s music have been reported even for patients who had already tried more than two types of antiepileptic drugs with no success; while drugs had failed to control their seizures, Mozart was able to significantly reduce or even completely abolish epileptic discharges.

The anti-epileptic effect of Mozart’s music has also been supported by animal studies, where it has been shown to reduce the frequency of spontaneous seizures in rats.

These studies were reviewed in a meta-analysis by Dastgheib and colleagues published in 2014 summarizing the effects of Mozart’s music on epilepsy. The authors found that 84% of the examined patients exhibited significantly reduced epileptic discharges following Mozart music therapy. Still, there have been some accounts of the opposite effect; in some cases, despite being a clear minority, Mozart’s music actually led to an increase in seizures.

But the positive effect of Mozart does not appear to be exclusive to that particular sonata. For example, recent studies have found that, in addition to Mozart’s K.448, also Mozart’s K.545 could reduce epileptic discharges.

The mechanisms of music’s effects

The mechanisms by which Mozart may act as an anticonvulsant are unknown. This effect has been attributed to fundamental elements of music such as its rhythmic structure and its lower harmonics. These characteristics may somehow activate neuronal networks by evoking neuronal patterns with anticonvulsant properties.

Epilepsy is a common neurological condition affecting around 1% of the world’s population. It is characterized by the recurrent occurrence of seizures, which are disturbances of the electrical activity in the brain. The type and frequency of seizures vary widely and affect different people in different ways. The causes of epilepsy are in many instances unknown and also highly variable, ranging from brain injury to substance abuse and even genetic factors.

Most patients with epilepsy achieve a remission in seizures with the currently available antiepileptic drug therapy. However, for around one third of the patients, remission is not effectively achieved, which means that seizures are recurrent, thereby affecting their quality of life and being at greater risk of depression, anxiety, and even death. These patients require multiple drug trials and, in some cases, even surgery or neurostimulation procedures.

The majority of focal seizures originate in the temporal lobe, a vital area for memory, language, auditory, and sensory processing. In a group of epilepsy conditions known as reflex epilepsies, seizures can be triggered by several different stimuli, the most common of which is light (photosensitivity). But other unusual (and surprising!) triggers have also been described in medical literature, such as reading, hot water, tooth brushing or eating.

Music also plays an important part in epilepsy. A great review by Melissa Maguire titled “Music and its association with epileptic disorders” was published in the volume “Music, Neurology, and Neuroscience: Evolution, the Musical Brain, Medical Conditions, and Therapies” of Progress in Brain Research, earlier this year.

As discussed in that review, the connection between music and epilepsy is very complex and interesting. This is because music actually has a dichotomous effect on epileptic seizures – in some patients, music brings benefit, while in others, music can trigger seizures and lead to musicophobia. And there are also those cases where musical hallucinations arise as part of an epileptic seizure.

Music as a trigger of epileptic seizures

This form of reflex epilepsy where patients experience seizures after listening to music is known as musicogenic epilepsy; it is rare, but it has been reported since the 19th century.

Although instrument playing-based training has been repeatedly reported to improve functional hand movements including grasping, the attempts to present quantitative information on physiological mechanism of grasping have been relatively insufficient to determine the type and the intensity of the exercises involved.

This study aimed to examine the muscle activation during hand percussion playing depending on the grasping type and the playing tempo. A total of twelve healthy older adults with a mean age of 71.5 years participated in this study. Surface electrodes were placed on three grasping-related muscles: Flexor digitorum superficialis, extensor digitorum, and flexor pollicis brevis. Participants were instructed to play with the egg shaker, paddle drum mallet and clave involving different types of grasp at three different tempi (i.e., 80, 100, and 120 bpm) and sEMG data were collected during each playing. Significantly greater muscle activation was generated with the small sphere type of egg shaker, compared to the handle type of paddle drum mallet and the small cylinder type of clave. Playing at faster tempo also elicited significantly greater muscle activation than at slower tempo. With regard to the rise time of muscle activation, while tempo significantly affected the rise time, the time to peak muscle activation did not significantly change depending on the grasping type.

This study confirmed that grasping pattern and the tempo of movement significantly influence the muscular activation of grasping involved in instrument playing. Based on these results, clinical implication for instrument selection and structured instrument playing would be suggested.